Provider Demographics
NPI:1578647871
Name:PHYSICIANS HEALTH NET, INC.
Entity Type:Organization
Organization Name:PHYSICIANS HEALTH NET, INC.
Other - Org Name:CENTRO MEDICO FAMILIAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRCHOU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-399-2345
Mailing Address - Street 1:865 N EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89101-2312
Mailing Address - Country:US
Mailing Address - Phone:702-399-2345
Mailing Address - Fax:
Practice Address - Street 1:865 N EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-2312
Practice Address - Country:US
Practice Address - Phone:702-399-2345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9244261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV32914Medicare ID - Type Unspecified
NVH11506Medicare UPIN